When it comes to fitting through the pelvis, head size is less important than is the angle of the baby’s head. A posterior baby will present a bigger head circumference and can sometimes get stuck in a pelvis that the same baby could have fit through if anterior. Whether or not the baby is actually too big, women may be told that a cesarean is necessary because “baby is too big.” Here’s how to tell if that’s true or not.
CPD vs. Posterior
How can we know if the angle of the baby’s head (presentation or position) is stopping the birth progress and requiring a cesarean?
To answer that question honestly, we must first support the natural physiology of birth. Freedom of movement, liberal access to food and fluids and a calm, supportive birthing environment work together to help labor progress normally.
When the physiology of birth is supported and the baby still doesn’t come with strong contractions, the first thing to consider is head angle, not head size. If we considered fetal rotation as a significant advance in labor progress, we might not have so many providers recommending surgery when the baby has finally rotated and the labor wanes. After rotation and a rest, labor will return. Patience is needed.
After repeat cesarean, lack of progress in labor is the 2nd most common reason for cesarean delivery in the United States, accounting for 30% of nearly one million cesareans performed annually. –Gifford et al, OB Gyn Vol. 95. No. 4, April 2000
The best way to know if a baby will fit through your pelvis is to labor in vertical positions with free access to labor foods and fluids.
These are good to drink in labor: Electrolyte drinks; such as, Hibiscus herbal tea, real grape juice, Recharge, Gatorade and Alacer Emergen-C
Women must eat over a long labor, small amounts periodically, or even a full meal if desired. This can make the difference whether normal labor can be strong enough to rotate baby’s head. This isn’t to say that midwives should bother a woman about eating. Watch for the woman who hasn’t eaten well through a long latent phase, is vomiting in early labor, or whose contractions have spaced out in late labor or pushing. A lot of honey and a few grains of bee pollen, perhaps, in 2nd stage helps those women whose contractions aren’t strong enough on their own to move baby down. Otherwise, the mother will tell you if she’s hungry. If a woman gets spacey and her contractions are spacey, too, a good bowl of sweetened oatmeal is worth trying before augmenting with drugs. Oatmeal is the midwives’ Pitocin. It works great around 7 am after a night up laboring.
Upright positions are important to help baby rotate. There is a technique to release possible tension or torsion (twisting) in the pelvic floor: The Pelvic Floor Release.
A birthing woman should be helped to be rested, fed and free to move with very strong labor contractions. Only after this, can you discover whether failure to progress is from CPD.
She can’t get through her labor if she doesn’t have hope. -Betty-Anne Daviss, CPM
The habit of many large, busy hospitals is to put women in bed in labor, and often with too many drugs to labor spontaneously.
Free movement, emotional support and a trusting relationship with your care providers can certainly help avoid surgical birth. Work with a doctor that you can have open communication with so that when your doctor says a cesarean is needed, you can trust him or her, and you can achieve a sense of acceptance (sometimes over time) with that decision.
Midwives, both Certified Professional Midwives (usually serving home birth families and birth centers) and Certified Nurse-Midwives (working in homes, birth centers or hospitals), have lower cesarean rates statistically than physicians — even physicians working with low-risk pregnant women. Individually, a provider can help reduce a woman’s chance of cesarean whether he or she is a doctor or a midwife. It’s not the title that decides whether a woman will be pressured into a cesarean, it’s the beliefs and the skills of the person as well as the communication and intent of the mother, her partner and her caregivers. A hospital nurse might have more to do with avoiding or arranging a cesarean than either the midwife or the doctor. A nurse who supports a birthing woman’s morale and knows a few fetal repositioning (rotation) tricks will help many women finish their births themselves and avoid major surgery. Any one of these providers might be the one to encourage a birthing woman in just the right way to finish a physiological birth when time and patience, or a series of techniques, were what was needed for baby to find the “hidden room” in the pelvis.
Working with a doula reduces the cesarean rate in all categories of providers.
If you have a history of a “CPD” diagnosis or are being told your baby is big, your support people and providers may need the spatial skills to help you with techniques to “open your pelvis.” One common mistake, though, is working on opening the wrong area of the pelvis. For instance, squatting or lunging when baby is high and not engaged even though labor has been active for a time.
Here are a few things to think about and to help you discern whether a cesarean is needed when the reason is “lack of progress.”
It’s not a lack of labor progress if its not even labor yet!
Latent labor is not active labor. Early labor is not active labor. Active labor begins about four (4) centimeters and the contractions are getting stronger and closer and lasting longer. A cesarean before 4 cm should not be done for “lack of labor progress.”
In other words, a cesarean at 3 cm for “lack of labor progress” or “failure to progress” is unjustifiable, even by ACOG standards, since active labor has not begun. Try these three instead: Rebozo Sifting, an inversion and end with a Sidelying Release.
Other reasons may make a cesarean necessary before 4 cm, and hopefully the decision to cut is not motivated by business management or, for that matter, fear management –yours or theirs.
To confirm the diagnosis of lack of progress, ACOG recommends that women be in the active phase of labor and show no change in cervical dilatation or descent of the fetal presenting part for at least 2 hours.
–Deidre Spelliscy Gifford, MD, MPH, Sally C. Morton, PhD, Mary Fiske, MD, MPH, Joan Keesey, Emmett Keeler, Phd, and Katherine L. Kahn. Lack of Progress in Labor as a Reason for Cesarean. MD Obstetrics & Gynecology 2000;95:589-595 © 2000 by The American College of Obstetricians and Gynecologists. Get a free copy of this inspiring article by Dr. Gifford and colleagues here.
However, lack of progress for two or more hours DOES NOT MEAN baby can’t be born vaginally and born healthy. We simply need to address the reason for the lack of progress:
- Is baby high? Help baby engage!
- Is baby near “zero station?” Often the cervix stalls at 7 cm (6-8 cm) because there is a tight pelvic floor. Try the Sidelying Release.
- Is the head low near the outlet? A myofascial release of the sacrum, a massage around the sacrum, getting out of bed and onto a stool or toilet, squatting, are some ways to open the outlet. Also try the technique for the midpelvis, the Sidelying Release (above), for the outlet. A deep warm water bath and privacy can help the perineum open.
- Crowning “forever?” Did the provider check for an intact hymenal ring? Get off the sacrum. Do a pelvic tilt to flatten the lumbar spine (posterior pelvic tilt) and hold the posterior pelvic tilt through one whole contraction.
Rotation is labor progress!
- Very strong contractions can happen when a posterior baby attempts to rotate to a better position to enter the pelvis. These strong contractions may not appear different from active labor. If the baby can make the rotation to LOT, labor will often become quite manageable and less painful–even at 8 cm (Sorry, this isn’t absolute after every rotation, but it does occur often). This means, that labor can seem like transition at 2 cm and like early labor at 8 cm for these women.
- Rotation is a significant sign of progress at any dilation.
- Rotation can be necessary before some women dilate past 4-5 cm. This means some labors will be strong and not continue to dilate the cervix at a steady rate. The cervix may stay at 3, 5, 7 or 9 cm dilated for 2-4 hours and then suddenly dilate to 10 following the rotation. See the labor section to see what to do in these cases. Waiting isn’t enough for some women and careful assessment by an experienced midwife, nurse or doctor is necessary to avoid clinical exhaustion, ketosis and death. Eating, drinking electrolyte drinks and snoring will help avoid these terrible but often relatively easily avoided problems.
- Complete rotation often precedes full dilation in most labors.
- Rotation can occur at the brim before or in early labor, at the pelvic floor around 4-5 cm, or after the head is completely through the pelvic bones and is beginning to crown (least often).
- First, do non-pharmaceutical relaxation methods to relax the involuntary muscles. More doulas, nurses and even physicians are using manteada (sifting) with the Rebozo, and craniosacral releases such as a diaphragmatic release or Pelvic Floor Release.
- If baby hasn’t rotated to LOT, encourage rest and food. Rest should include some amount of snoring and it often takes a mature and motherly persuasion to get an anxious and exhausted birthing woman to sleep. I don’t suggest morphine, because of the risk of adding 12-24 hours of ineffective labor and possible respiratory problems for baby after birth, even if birth comes 24 hours later. See the labor pages for comfort measures for labor.
When rotation takes place during a long labor, rest will be needed. Contractions space out. A lull in labor doesn’t mean the baby doesn’t fit. It means the uterus is getting well-earned rest.
Once the baby has rotated, a tired mother will need rest. Medicated rest to slow labor down and let a woman sleep may very likely make medicated (Pitocin) augmentation of labor necessary to speed labor up after the rest. Please try a rest without drugs first. A soothing back rub and quiet, lulling whispers may relax a mother’s mind. A nap in a pool supported with pillows, floats, rolled towels, etc. is a favorite of many women in long labors.
After 2-6 hours of good sleep or accumulated micro naps of 2-5 minutes each (with snoring or drooling!) a mother may wake and eat and begin to move around. Contractions will resume and more movement such as dipping in and out of squats or lunging will bring on the contractions strongly enough to bring the baby through the pelvis. Don’t forget midwives’ pitocin – oatmeal!
Other labors will continue without a lull because the chin is tucked and the uterus is willing.
Chin tucking is as important as rotation!
Chin tucking, whether before or after rotation, is often necessary before a vaginal birth is possible. Some posterior babies can be born vaginally even with their chins extended. Read the true story, The Long Labor that Wasn’t (Long).
Exceptions rely on either a large pelvic outlet or a premature baby or fantastic pelvic movement and vertical positions or vacuum extraction.
Chin tucking can take hours. Sitting on a birthing ball and making VIGOROUS circles with your hips will reduce the time it takes. The more vigorous the circles, the faster the chin will tuck. Have someone with you and hang on to the hospital bed frame or similar steady object so you don’t slip or wobble.
On the other hand, chin tucking can happen easily, with early labor contractions, or even when a woman is asleep. Doing things that balance the body help the baby to be flexed and ready.
Angle is often more important than size. A baby in an ideal laboring position can be persuaded through a well-shaped, even if small, pelvis through movement and good contractions.
If the baby can’t get the angle hoped for, than size might matter. Moving the pelvis and using vertical positioning, sometimes even using artificial oxytocin (Pitocin) can help when the baby is only a little big for the mom. I’ve seen several women who were 5 feet tall, or a little more, have nine, ten and even eleven pound babies.
Hip size doesn’t accurately reveal the size of the inside of the pelvic “tunnel.”
Change the size of your pelvis!
Pelvic size changes somewhat with various maternal positions. Hands-and-knees position, and squatting both open the pelvis by two centimeters. That’s a lot more room for a baby to use to come down.
Squatting is especially good once the head becomes visible. Even if the nurse, separating the labia, can just see the head. The outlet widens from squatting.
Practice squatting every day in pregnancy. Take it slow and see tips on Daily Activities.
Lying on one’s back disables the sacrum from opening outward as the head passes by. Is it true that a baby didn’t fit, or was it the custom of birthing on one’s back that led to surgery or a bad tear?
Most babies will be rotating when their parietal bone presses down on the edge of the opening in the pelvic floor. That’s at about 5 cm for a first-time mom and not until 8 or 10 cm with moms who have given birth before.
When the baby has to rotate from the right side to the left, or the posterior to the anterior, the cervix may be at one particular centimeter of dilation for 3-4 hours or even more. A stall in dilation by itself is not CPD. You have to look at more indicators. Often, after the stall the cervix opens rapidly as the baby has made the change. It’s not the cervix, but the application of the head to the cervix and the angle of the head in the pelvis that needs addressing.
Up to eight percent (8%) of babies will not rotate before delivery (whether vaginal birth or delivery by cesarean after labor).
Obstetrical patients among the medical studies were able to give birth vaginally to only half of these persistent posterior babies.
Epidural anesthesia can make 12% of all babies end up in the posterior position. See Dr. Leiberman’s 2005 study on Changes in Fetal Position. See my discussion of the Leiberman study on this website.
There are occasional situations when a baby can’t rotate and so, for that baby and that mama, the baby won’t fit the pelvis.
Pelvic shape has an effect on rotation. Two pelvic shapes sometimes limit a posterior baby’s options. The android and the anthropoid. If the baby has already dipped lower than the pelvic brim (entrance) the baby may not be able to rotate until first having descended all the way down through the pelvis and onto the perineum (which is below the lower part of the bony pelvis).
Can we know before labor if the baby won’t fit?
There is no chart or even a realistic guideline to show which size head would fit. And ultrasound is not excellent at measuring fetal heads at the time of birth anyway. Labor itself is the key. The pelvis opens wider during labor, and with good maternal positioning (think gravity). Baby’s head will mold, too. So, a chart or a “rule” about head size is not useful.
Read the next portion to see the difference between a CPD labor pattern and a posterior labor pattern in which the baby can fit after rotation (Some posterior babies fit without needing to rotate, remember. Their mother’s may have a gynecoid or, more likely, an anthropoid shaped pelvis).
If the baby on the right can’t rotate, a cesarean will have to be done. Whereas, the baby on the left fits the mother’s pelvis, in spite of being posterior. The baby on the right needs Abdominal Lift and Tuck for ten contractions in a row, as best a woman can fit in. If that doesn’t work, then do Walcher’s to Open the Brim.
A Dissent in Descent
There are times when a baby can’t descend because he or she doesn’t fit.
There are times when even a rotated and nicely tucked baby won’t fit the pelvis. Try the sidelying release and see if the reason is muscle tension before assuming it’s the size of the bony pelvis. The labor may rest for an hour and resume with gusto afterwards to show it was muscle tension. If one waits for many hours, it’s important that mom and baby are healthy and willing to test out the labor pattern.
Transition-like contractions (90 seconds every 2 1/2 minutes) and vertical positions and active movement has been tried for about 4 hours.
Pitocin has been tried when needed to bring contractions significantly strong enough to meet the previously mentioned pattern.
Labor Pattern with CPD
Natural labor contractions stop fairly abruptly– often just as the midwife is setting up her instruments because the labor seems like transition.
Or, with strong, strong contractions, dilation remains at a standstill. There is no fetal descent and no change in chin tucking or rotation. These two seem opposite, but these scenarios show the two common labor patterns with CPD.
Careful vaginal exams note the relationship between the baby’s head revealing the amount of flexion (chin tucking) and whether this is changing, which often precedes descent and dilation.
Several studies show that an internal exam is only 60% accurate in the dilation stage of labor. It’s better in the pushing stage, but not even 90% of the time. That means that an internal exam may not be able to distinguish the direction that the baby is facing.
Labor comes on like blazes and suddenly halts. Contractions may stop entirely for many hours or a day or two. These are not the usual warm-ups or “false labor” or late pregnancy “turning contractions.”
Another failure to complete rotation happens when a baby gets caught in a transverse arrest. Before or during rotation the baby temporarily faces a hip and in transverse arrest gets stuck there on the ischial spine halfway down the inside of the pelvis. Gifford found that up to 24% of cesareans for lack of progress are to rescue the transverse arrest babies.
Check these three things when deciding if “you’ve done everything”:
- Physically nourished. Does the mother have nutritional reserves? Is she eating? Is the mother reasonably rested? Can we get her to sleep with back rubs and such (without medications which can make the uterus too sloshy to pick up the tempo again)?
- Appropriate movement of the pelvis. When mothers can’t rest, or don’t need to, then it’s a good idea to move the pelvis in ways that help chin tucking, rotation and then, descent. Too many mothers and their caregivers think a walk around the maternity floor is enough movement. It’s not for a posterior baby in a first-time mom. If the usual active birthing posture(s) don’t bring baby down, try:
- Abdominal lift and tuck for 10 contractions in a row
- Walcher’s Trochanter Roll for 3 contractions in a row
- Pelvic Floor Release for 2-3 contractions in a row. You must repeat on the other side or you might make matters worse. Be balanced.
- Strong contractions. Dipping and squatting and bring on contractions by a variety of natural and medicinal ways may be necessary to help a posterior baby rotate. This is when Pitocin by IV tube can be helpful. There are ways to cope with Pitocin without an epidural and it is worth it to see if the mother can before she accepts an epidural at this time. Her options reduce dramatically when she is confined to bed by the epidural which numbs her legs. Also the epidural may soften the lower uterine segment. Then the baby who is trying to rotate can slip back to a direct OP position and not be able to rotate. If so, the chance of needing a cesarean to finish labor is high.
Having labor is really worth it to the baby and the breastfeeding mother. Nursing more often goes better after a labor. This seems to be true, in large numbers of women, even if the mother needs a cesarean to finish labor.
Real Story: Why doesn’t the baby drop or engage??
On Fri, Oct 23, 2009 …”S.” wrote:
I’ve been following your website through the advice of the doula for my first birth in 2007 and I was wondering if you had any advice for me. Here’s my story:
I used the techniques for my first baby and she was consistently in LOA position throughout the second half of my pregnancy. I labored with her naturally for 40 hours, finally asked for an epidural, and then after 49 hours of only getting to 6 cm, ended up with an emergency C-section. The nurses were so frustrated every time they checked me because they kept saying that the baby was still just floating up so high and they couldn’t figure out why. My water had broken on it’s own about half way through my labor and we tried every position imaginable from standing, squatting, lunging, dangling, etc. and she just never engaged.
I’m now pregnant with our second and again the baby is in LOA – the exact same place. We assumed the first time was something of a fluke and had been planning a VBAC. My due date is tomorrow and this baby is still up under my ribs! I know that second babies don’t usually engage until labor begins, but I was wondering if you found that to be the case if a first baby never engaged? My Dr., although very supportive of VBACs, is beginning to wonder with no cervical changes at all and the baby being so high, if I will actually be able to successfully deliver vaginally based on my first experience. He won’t induce me (which I don’t want anyway) and he knows I’m desperate to avoid a repeat of my first labor and birth.
I’m trying daily inversions and pelvic floor release to see if that helps, but do you have any thoughts at all about my situation? I’m sooooooo open to anything at this point!
Thanks for any advice!
– S. in North Carolina, USA
Gail gives a lengthy reply:
I am so glad you emailed!
There are two possible things that comes to mind,
- One is the alignment of your pelvic brim .
- Second is the size of your pelvic brim.
- The third possible thing is the thing I haven’t thought of… We’re all still learning.
For most people who’s baby is really actually in the LOA position, as you find your baby, then the angle of the baby’s head is already at its smallest diameter. So I am eliminating the most common reason that babies are high and unengaged – the posterior and or deflexed head. An LOA baby can be deflexed.
To check head flexion the midwife or doctor checks to see if the cephalic prominence is felt on the opposite side of the baby’s back. In your case, the cephalic prominence should be felt on your right. If so, the cephalic prominence is the baby’s forehead. If that IS the case, the baby IS in the best position for engagement.
An LOA baby might also be unusually asynclitic, in which case, the smallest diameter is not available, but, in this highly unusual situation (probably not your situation) might be considered. The baby is supposed to be slightly asynclitic to get into the brim and past the sacral promontory, but if severely asynclitic it would relate to a twist or torsion in your uterine ligaments. Again, this is unlikely, but I mention it.
If your baby’s cephalic prominence is on the same side as the baby’s back, then the chin is extended and a larger diameter of the baby’s head is presenting.
Then you can do exercises to help the chin tuck to the baby’s chest.
You may benefit from Chiropractic adjustment and myofascial release, or skilled Maya massage as well. Practitioners should have lots and lots of experience with pregnancy. The formula they learned in class is not enough for a specific need. They should have an ideal of the needs of your situation to help the ligaments and pelvis.
Chiropractic alignment includes attention to the SI joints (both) the symphysis (sometimes overlooked) and the sacral axis, vertical (ala are vertically twisted) and horizontal (buckled sacrum maneuver), as well as the neck and respiratory diaphragm.
Myofascial release involves the buckled sacrum maneuver or standing sacral release (same thing); pelvic floor release; abdominal release; and perhaps, the respiratory diaphragm (indigestion, heartburn, trouble breathing when lying down, lower rib pain, asthma, long-term cough, are symptoms that clue us to respiratory diaphragm tension).
Craniosacral therapy can be helpful if you have a chronic symptom, which you do. And if chiropractic hasn’t had a notable or a lasting effect. CST attends to the fascia in ways the other two modalities can’t quite reach and helps them work better just as they help CST. So I see the three working together.
Now that gets expensive.
On my site I talk about and show how to do the Rebozo jiggling, the Inversion and the pelvic floor release. Your baby is LOA, so we can expect that your upper uterine ligament – the broad ligament – is probably balanced. The lower ones may be, too.
These exercises may still be helpful to your pelvis, especially repeated use of the Leaning-forward inversion for short, 30-second periods, not longer. Not longer!
So, if your pelvis and ligaments are balanced and your baby is still not dropping, we are having to look CPD right in the eye.
Cephalo-pelvic disproportion means that the pelvis is too small for the baby.
Why could this happen? Some pelvis brims or outlets are not fully-opened and balanced. It can take a skilled practitioner to catch that and correct it. A tight tendon or ligament in one area constricts the pelvis in another area. It’s correctable.
Some pelvises are really too small due to malnutrition rickets, lack of Vitamin D in the developmental years (living in the northern hemispheres, living in the city, playing inside as a child, not absorbing vitamin D well…?). It’s not really correctable.
How do you know if its CPD?
4 hours of good strong contractions, 90 seconds long, 2 1/2 – 3 minutes apart with no descent of the LOT or LOA baby. Mother is in a vertical position.
If you do have a small pelvis and you get your baby engaged and moving down the pelvis. You would want to sit on a birthing stool, or stand for the entire pushing phase!!! Don’t lay on your back. We want the baby to make it entirely through your pelvis, not just into your pelvis, right?
Women with CPD can go into labor and go to the hospital for a cesarean birth. This allows the baby to trigger labor his or herself and yet have the only safe passage in their situation. They get that. Labor doesn’t have to last any particular length of time, as far as I know, to give the baby a burst of blood chemicals to help the transition to life in the air, but starting labor spontaneously, not by induction, is protective.
Will induction prevent CPD and cesarean? Not likely. Studies don’t support that, but it may work on an individual basis.
YOU are the Mama, you get to pick.
I guess the fourth thing that some would say is emotional issues. Is there an unhealthy/unsafe interpretation of your birthing parts that has created the idea that it isn’t safe or good for a baby to be associated with your sexual parts? Self-hatred caused by sexual abuse can stop a woman from letting her baby into harm’s way (as she sees it). Reclaiming your body as your own, as holy and pure, as not belonging to a perpetrator or his/her cursed belief system can reclaim your body for you and your baby. I’m not saying that this is your situation. But I am listing every possible reason, and this has been a reason for some women. You probably know immediately if this concerns your situation or not. If not, journaling to find out if this might be so or not may be painful, but useful. Don’t do it without kindness to yourself and support for the journey!!
We must know that our bodies are our practical homes, created for life and love, and are not the place for sick people to dump their torture. The beauty of womanhood and motherhood is above all that. Every woman deserves self respect. [drum roll sounds]
Meanwhile, eat sensibly without sugar, junk, or white flour. Walk daily, swim and/or dance. Love your baby and have fun with this precious time.
Let me know whether any of this makes any sense to you and whether I can publish our email exchange. There are plenty of things I don’t know and I’m always eager to learn. So if you find out anything else, please let me in on it!!! Thank you.
Happiness on your journey,
S writes back:
Thanks so much for all of this information! I’m continuing to digest it all and will definitely let you know what comes of all of our efforts. If nothing else, I have a lot more information and questions to discuss with my care provider this week in regards to determining what we might actually be dealing with. Regardless of how we end up bringing this little one into the world, I know that I will feel more empowered this time around simply for the fact that I have further information and education to make the choices instead of having them made for me. Your website has been a wonderful resource throughout both of my pregnancies!
Feel free to publish anything that you feel would be helpful to others.
Thanks so much!